Schoenbrunn Healthcare

In the surveyor’s words

From the most serious findings on record at Schoenbrunn Healthcare, in the surveyor’s own words.

• Actual harm, isolatedF600Oct 18, 2024

  Based on medical record review, review of a facility self-reported incident (SRI) and investigation, review of a personnel records, review of staff schedules and time punches, facility policy review and interviews, the facility failed to ensure Resident #03 was free from an incident of staff to resident abuse which included intimidation, verbal and emotional abuse. Actual psychosocial harm occurred on 09/30/24 to Resident #03 when State tested Nursing Assistant (STNA) #174, while providing care for the resident, yelled, used profanity and punched/hit the wall above the resident's bed. Resident #03 believed STNA #174's actions were directed toward her. […]

• No harm, potential for more than minimal, widespreadF812May 21, 2026

  Based on observation, interview and review of facility policy the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all 91 residents receiving meals from the kitchen. The facility identified one resident (#9) who did not eat by mouth (NPO). The facility census was 92. Findings include:Observation during the initial tour of the kitchen on 05/21/26 at 8:15 A.M. revealed a 25-pound box of rice was open to air with the rice exposed to the air in the dry storage room. An interview at this time with Manager-in-Training (MIT) #412 verified the rice was open to air and should be in an airtight container. Observation on 05/21/26 at 11:50 A.M. […]

• No harm, potential for more than minimal, widespreadF801Mar 26, 2026

  Based on personnel record review, observation and interview, the facility failed to employ a qualified director of food and nutrition services (Dietary Manager) and educate dietary aides. This affected all 86 residents in the facility. The facility census was 86.Findings include: Interview on 03/23/26 at 9:43 A.M. with the Administrator revealed they have a company called Health Care Services Group (HCSG) that started as a contract company to run the kitchen. The facility uses their employees and conduct oversight.Review of personnel credentials revealed Dietary Manager #217 did not have the qualifications to be a Dietary Manager. She was not certified and her degrees were not in the areas to qualify her for the position, despite her years of working in a kitchen. […]

• No harm, potential for more than minimal, widespreadF804Mar 26, 2026

  Based on observation, test tray, and interview, the facility failed to ensure food was prepared by methods that conserve nutritive value, flavor, and appearance. This had the potential to affect all 86 residents in the facility.Findings include:1.Observation of the lunch meal on 03/23/26 revealed the Lifebridge Unit was the last hall to be served. The dining cart with trays arrived at 1:15 P.M. Observation and interviews related to the meal appearance and palatability revealed on 03/26/26 at 1:25 P.M. Resident #78 was sitting on the side of the bed eating his lunch. The resident appeared to have two bowls of pasta salad on his tray that he was eating with a fork. The surveyor commented related to the pasta salad and Resident #78 revealed the bowls were chicken noodle soup not pasta salad. […]

• No harm, potential for more than minimal, widespreadF806Mar 26, 2026

  Based on menu review and interview, the facility failed to ensure appealing options of similar nutritive value were available to residents who chose not to eat food that was initially served or who requested a different meal choice. This had the potential to affect all 86 residents in the facility. The facility census was 86.Findings include:Interview on 03/23/26 at 11:02 A.M. with Dietary Manager #217 revealed the kitchen needed major plumbing work where the cement floor was removed in areas to access broken pipes in the kitchen and dry storage. They had no use of the kitchen during 19 days of replacing the pipes and re-cementing the floor. […]